What are the typical protocols for managing type 2 diabetes?

Management Protocols for Type 2 Diabetes

Metformin combined with lifestyle modifications should be the first-line therapy for most adults with type 2 diabetes, with SGLT-2 inhibitors or GLP-1 receptor agonists added for patients with inadequate glycemic control or those with cardiovascular/renal comorbidities. 1

Initial Assessment and Treatment Algorithm

Step 1: Initial Therapy

• For most adults with newly diagnosed T2DM:

  • Start metformin (titrate up to 2,000 mg daily in divided doses) 1
  • Implement intensive lifestyle modifications (diet, exercise, weight management)
  • Target HbA1c: 7-8% for most adults 1

• For patients with specific presentations:

  • If ketotic/in diabetic ketoacidosis: Start insulin therapy
  • If random blood glucose ≥250 mg/dL or HbA1c >9%: Consider initial insulin therapy 1
  • If cardiovascular disease or CKD: Consider early addition of SGLT-2 inhibitor or GLP-1 receptor agonist 1

Step 2: Monitoring and Intensification

• Monitor HbA1c every 3 months

• If treatment goals not met after 3 months, intensify therapy:

  • Add SGLT-2 inhibitor if patient has:

    • Heart failure
    • Chronic kidney disease
    • High cardiovascular risk

  • Add GLP-1 receptor agonist if patient has:

    • Increased stroke risk
    • Weight loss as important goal
    • Established atherosclerotic cardiovascular disease

• Avoid adding DPP-4 inhibitors (inferior mortality/morbidity outcomes) 1

Lifestyle Modification Components

Physical Activity Protocol

• Aerobic exercise:

  • Minimum 150 minutes/week of moderate-intensity activity
  • Sessions should last at least 10 minutes, aiming for 30 minutes daily
  • No more than 2 days should elapse between exercise sessions 1

• Resistance exercise:

  • 2-3 sessions weekly on non-consecutive days
  • At least one set of 5+ different exercises involving large muscle groups 1

• Sedentary behavior:

  • Break up prolonged sitting (≥30 minutes) with brief standing or walking 1

Nutrition Protocol

• Focus on foods high in fiber (vegetables, fruits, whole grains, legumes)
• Emphasize low-fat dairy products and fresh fish
• Limit high-energy foods rich in saturated fats and sweet desserts/snacks 1
• No specific diet has proven most effective, but weight reduction of 5-10% significantly improves glycemic control 2

Special Population Considerations

Children and Adolescents with T2DM

• Initial therapy:

  • If ketotic/DKA: Start insulin therapy
  • If HbA1c ≥8.5%: Consider insulin therapy
  • If HbA1c <8.5% without ketosis: Start metformin (titrate to 2,000 mg daily) 1

• If glycemic goals not met:

  • Consider adding GLP-1 receptor agonist approved for youth
  • Consider insulin therapy (may exceed 1 unit/kg/day) 1

• Monitoring:

  • Regular blood glucose monitoring for those on insulin or medications with hypoglycemia risk
  • Consider CGM for patients requiring frequent monitoring 1

Medication Management Pearls

• When adding SGLT-2 inhibitors or GLP-1 agonists with adequate glycemic control, reduce or discontinue sulfonylureas or long-acting insulins to minimize hypoglycemia risk 1

• For patients on insulin and planning exercise:

  • May need additional carbohydrate intake if pre-exercise glucose <100 mg/dL
  • Consider reducing insulin doses for planned exercise
  • Be aware that intense activities may paradoxically raise blood glucose levels, especially if pre-exercise levels are elevated 1

• Pioglitazone (thiazolidinedione class) should be taken once daily without regard to meals, starting at 15-30 mg and titrating up to 45 mg if needed 3

Common Pitfalls to Avoid

1. Failure to individualize HbA1c targets - Aim for 7-8% for most adults, but consider less stringent targets for patients with limited life expectancy, history of severe hypoglycemia, or advanced complications 1

2. Overlooking cardiovascular risk management - Type 2 diabetes management must include aggressive management of cardiovascular risk factors (hypertension, dyslipidemia) 4

3. Delaying intensification - Don't delay adding second-line agents when glycemic targets aren't met with metformin alone

4. Neglecting weight management - Weight loss of 5-10% can significantly improve insulin sensitivity and glycemic control 5

5. Focusing solely on medication - Lifestyle modifications are fundamental to diabetes management and should be emphasized at every visit, not just as initial therapy 1